Normokinetic Biliary Dyskinesia: A Novel Diagnosis

Background:Biliary dyskinesia diagnosed with CCK-HIDA scan and ejection fraction less than 35% has been successfully treated by laparoscopic cholecystectomy, with resolution of symptoms ranging from 77%-97%. However, there is a population of patients with symptomatic biliary pain who are negatively worked-up, including a “normal” CCK-HIDA scan with ejection fraction greater than 35% that never receive a diagnosis, and thus no definitive treatment. For some of these patients their symptomatic biliary pain is reproduced during their CCK-HIDA. It is believed these patients have a novel diagnosis, Normokinetic Biliary Dyskinesia (NBD). NBD consists of an ejection fraction greater than 35%, a complete negative work up, and reproducible biliary pain with CCK-HIDA scan. It is hypothesized these patients will have resolution of biliary pain when treated with cholecystectomy. Methods:With approval of the Institutional Review Board, a retrospective chart review was completed looking for patients with biliary pain in accordance with the ROME III criteria. Patient inclusion consisted of those with a negative work-up (minimum of normal ultrasound of the gallbladder and normal upper endoscopy), documented reproducible biliary symptoms on administration of CCK during their HIDA scan, and an ejection fraction greater than 35%. Treatment modality was laparoscopic cholecystectomy. Data points included: age, sex, duration of symptoms, biliary ejection fraction, duration of follow up, resolution of symptoms, type of surgery, and final pathology.Results: Over a three year period from August 2008 until July 2011, 19 patients were found to fit the inclusion criteria for this study. All had documented reproducible biliary pain on administration of CCK during the HIDA scan and an ejection fraction greater than 35%, with a complete negative work up. There were 15 women and 4 men with a mean age of 48.4±13.0 years, all had an ejection fraction greater than 35% with a mean of 75.1±19.8%. The average duration of pre-operative symptoms was 7±6 months and the average post-operative follow up was 6±3.5 months. Patients were followed in clinic and contacted at the termination of this study. All patients were treated with laparoscopic cholecystectomy. On final pathology 18 patients had chronic choelcystitis, and one patient had chronic cholecystitis with cholesterolosis. Of the patients included in this study, 16 had complete resolution of symptoms, two had partial resolution, and one had no change. There was a complete resolution rate of 84.2% and an improvement rate of 94.7%. Conclusion:Utility of treating biliary dyskinesia diagnosed by CCK-HIDA and ejection fraction less than 35% with laparoscopic cholecystectomy has been established in the literature. We suggest that those patients who present with biliary pain, a complete negative work up, and reproducible symptoms on administration of CCK during their HIDA scan, will benefit from cholecystectomy regardless of ejection fraction. Those who will benefit greatest from this are those with an ejection fraction greater than 35% who currently are excluded from the diagnosis of biliary dyskinesia, and thus treatment. We hypothesize a new diagnosis, Normokinetic Biliary Dyskinesia and recommend cholecystectomy as treatment.

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